Transcription of Application to Amend a Tennessee Birth Record
1 Tennessee DEPARTMENT OF HEALTH. OFFICE OF VITAL RECORDS. Application TO Amend A Tennessee Birth Record . (Please print). Applicant's Name: _____. Street Address: _____. City: _____ State: _____ Zip Code: _____ Phone: _____. Signature: _____Relationship to Registrant:_____. Part I. Complete 1-7 with the information as shown on the Record . If the child's name does not appear on the Birth Record , enter Not shown in the first item. (Type or print). 1. Full Name of Child (Registrant) 2. Date of Birth 3. County of Birth 4. Sex 5. State File Number (if known). 6. Full Name of Father (if listed on the Birth Record ) 7. Full Maiden Name of Mother Part II. List the item and information that you want corrected on the Record .
2 (Type or print). Items to be corrected Information currently listed Information that should appear on the Record Part III. The affidavit should be signed by the registrant (must be at least 18 years of age), parent(s) listed on Birth Record , or legal guardian (provide a copy of guardianship papers). This MUST be signed in front of a Notary Public. I/ _____, make oath the information above is true and correct. Please Print the Name(s). _____ _____. *Signature *Signature Relationship to Registrant_____ Relationship to Registrant_____. Sworn to and subscribed before me on_____/_____/_____ Sworn to and subscribed before me on_____/_____/_____. in the State of _____, County of _____.
3 In the State of _____, County of _____. SEAL SEAL. _____ _____. Signature of Notary Public Signature of Notary Public _____ _____. My commission expires My commission expires PH-1186 (rev 4/2017) RDA 1785. PH-1186 (rev 9/2017) RDA 10113. _____. Part IV. Examples of amendments and the suggested types of documents used to Amend a Birth Record . Generally, the affidavit and one acceptable document are sufficient. Note: Some amendments may require additional documentary evidence. No white-out, cross outs, or erasures. Examples of amendments on Birth records Types of documents Name of Child A. Not Named at Birth Under one year old .. affidavit signed by parents listed on Birth Record (no evidence needed).
4 Age 18 and older .. affidavit signed by a parent listed on the Birth Record (no evidence needed) OR. affidavit signed by registrant (18 or older) and at least one document from Part V. B. Minor Changes to Spelling. affidavit signed by registrant or parent and at least one document from Part V. (Significant changes to a name could require a court order.). C. Change the Last Name a certified court order (for instructions on how to obtain an order, contact the court clerk's office in your county of residence). D. Spelling of Last Name of Child and Parent ..affidavit signed by registrant or a parent listed on the Birth Record and a copy of the parent's Birth Record , parent's death Record (must be at least 5 years old) or a copy of sibling's Birth Record Date of Birth A.
5 Month and/or Year affidavit and one document from Part V created prior to 10th birthday (If changing the year of Birth , provide a list of registrant's brothers and sisters with their dates of Birth .). B. Day affidavit and one document from Part V created prior to 21st birthday Parents' Information A. Minor Spelling Corrections, Date of Birth , or State of Birth ..affidavit of parent and a copy of his/her Birth Record B. Mother's Current Legal Name .only minor spelling corrections with affidavit of parent and a copy of her Birth Record (a court order is required for adding or changing names). C. A court order is required to make any changes to the father's information when a Voluntary Acknowledgment of Paternity has been completed.
6 Part V. Suggested types of documentary evidence. The document must show the correct information requested long with the person's full name, age or date of Birth , and the date the Record was made. The document should be the closest available Record after Birth unless otherwise stated on this form. A document's acceptability is at the discretion of our office. *School Record *Child's Birth certificate *Marriage certificate *Parent's Birth or death certificate *Medical Record *DD-214. This Application should not be used for: *Adding or removing a father *Complete change of last name for registrant or parents *Court ordered changes (legal name changes, adoptions, paternity establishment *Filing a delayed certificate of Birth This Application , supporting document(s), and the amendment fee of $ should be submitted to: TN Vital Records 710 James Robertson Parkway This fee does not include the cost of a certified copy of the Record after the amendment is 1st Floor Andrew Johnson Tower completed.)
7 Enclose the additional fee of $ for a certified long form copy of the Birth Nashville, TN 37243. Record ; additional copies are $ each. PH-1186 (rev 9/2017) RDA 10113.
